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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804122
Report Date: 08/29/2023
Date Signed: 08/29/2023 02:57:12 PM


Document Has Been Signed on 08/29/2023 02:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:MIRABEL LODGEFACILITY NUMBER:
496804122
ADMINISTRATOR:VARSHAVSKY, ALEXANDERFACILITY TYPE:
740
ADDRESS:6950 MIRABEL ROADTELEPHONE:
(707) 887-1754
CITY:FORESTVILLESTATE: CAZIP CODE:
95436
CAPACITY:34CENSUS: 28DATE:
08/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:Diandra Chadwick (Lead staff)TIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced at the home for the purpose of conducting a case management inspection and met with Lead staff Diandra Chadwick and owner Julia Latifi. The purpose of this case management inspection is to follow up on two self reported incident report submitted to Community Care Licensing (CCL) on 8/4/23 and 8/18/23 respectively.

Per incident report dated 8/4/23, on 7/9/23 resident (R1) complained that they were not feeling good and staff conducted an assessment that appeared like R1's left side of their face was dropping, staff called 911 immediately and R1 was transported to the hospital for further evaluation. Responsible parties were notified. Discharge documents stated that R1 was diagnosed with hypokalemia with no follow up appointments nor medication changes. During today's visit, LPA reviewed R1's physician report dated and care plan does not indicate any change of condition.

Per other incident report dated 8/18/23, on 8/11/23 staff heard the alarm sounding and approached to check on resident (R2) and found them on the floor, R2 stated that they were trying to use the restroom and didn't make it slipped, fell hitting their head, scrapped their back so staff called 911 to have R2 transported to the hospital for further evaluation. Discharge documents dated 8/11/23 indicate that R2 were treated for scalp laceration staples that will be removed in clinic in 7 days with no changes in medication. Based on records review and interviews with facility staff, the facility followed all regulation and training requirements.

No deficiencies cited during today's inspection.

Exit interview conducted with Licensee and a copy of this report was provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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